Knowledge and practices of modern contraceptives among religious minority (Muslim) women: A cross-sectional study from Southern Nepal

Background Uptake of family planning (FP) services could prevent many unwanted pregnancies, and unsafe abortions and avert maternal deaths. However, women, especially from ethnic and religious minorities, have a low practice of contraceptives in Nepal. This study examined the knowledge and practices of modern contraceptive methods among Muslim women in Nepal. Methods A cross-sectional study was conducted among 400 Muslim women in the Khajura Rural Municipality of Banke district. Data were collected using face to face structured interviews. Two outcome variables included i) knowledge of and ii) practices of contraceptives. Knowledge and practice scores were estimated using the list of questions. Using median as a cut-off point, scores were categorised into two categories for each outcome variable (e.g., good knowledge and poor knowledge). Independent variables were several sociodemographic factors. The study employed logistic regression analysis, and odds ratios (OR) were reported with 95% confidence intervals (CIs) at a significance level of p<0.05 (two-tailed). Results Almost two-thirds (69.2%) of respondents had good knowledge of modern contraceptive methods, but only 47.3% practised these methods. Women of nuclear family (adjusted odds ratio (aOR) = 0.60; 95% CI: 0.38,0.95), and who work in agricultural sector (aOR = 0.38; 95% CI: 0.22, 0.64) were less likely to have good knowledge on modern contraceptives. Women with primary (aOR = 2.59; 95% CI: 1.43, 4.72), secondary and above education (aOR = 4.41; 95% CI:2.02,9.63), women with good knowledge of modern contraceptives (aOR = 2.73; 95% CI: 1.66, 4.51), who ever visited a health facility for FP counselling (aOR = 4.40; 95% CI: 2.58, 7.50) had higher odds of modern contraceptives practices. Conclusion Muslim women had low use of modern contraceptive methods despite having satisfactory knowledge about them. There is a need for more equitable and focused high-quality FP practices. Targeted interventions are needed to increase the knowledge and practices of contraceptives in the Muslim community. The study highlights the need to target FP interventions among socially disadvantaged women, those living in a nuclear family, and those with poor knowledge of modern contraceptives.


Background
Uptake of family planning (FP) services could prevent many unwanted pregnancies, unsafe abortions and avert maternal deaths. Women, especially from ethnic and religious minorities, have low practice of contraceptives in Nepal. This study examined the knowledge and practices of modern contraceptive methods among Muslim women in Nepal.

Methods
A cross-sectional study was conducted among 400 Muslim women in Khajura Rural Municipality of Banke district. Data were collected using face to face semi-structured interviews. The status of knowledge and practice of modern contraceptive methods were analysed by different socioeconomic factors.

Conclusion
Muslim women had low practices despite having satisfactory knowledge of modern contraceptive methods. There is a need for more equitable and focused high-quality FP practices. Targeted interventions are needed to increase the knowledge and practices of contraceptives in the Muslim community. Such interventions include mobilisation of health workers (HWs) from their community, awareness on contraceptive methods embedding with values and culture of the Muslim religion.  The authors have declared that no completing interests exist.

Background
Uptake of family planning (FP) services could prevent many unwanted pregnancies, unsafe abortions and avert maternal deaths. Women, especially from ethnic and religious minorities, have low practice of contraceptives in Nepal. This study examined the knowledge and practices of modern contraceptive methods among Muslim women in Nepal.

Methods
A cross-sectional study was conducted among 400 Muslim women in Khajura Rural Municipality of Banke district. Data were collected using face to face semi-structured interviews.
The status of knowledge and practice of modern contraceptive methods were analysed by different socioeconomic factors.

Conclusion
Muslim women had low practices despite having satisfactory knowledge of modern contraceptive methods. There is a need for more equitable and focused high-quality FP practices.
Targeted interventions are needed to increase the knowledge and practices of contraceptives in the Muslim community. Such interventions include mobilisation of health workers (HWs) from

Introduction
Family planning (FP) is one of the high impact interventions that prevent unintended pregnancies, unsafe abortions, reduce high-risk births, avert maternal and neonatal deaths, and protect women and children's health [1][2][3][4]. Despite multiple benefits, many women in need of FP methods, cannot access the FP services. This unmet need for FP results in approximately 539,000 annual unintended pregnancies in Nepal [5,6]. These unintended pregnancies can pose serious health risks to mothers and their newborns, including deaths [7]. The risks of maternal morbidity and mortality are also high among poor, rural women who have been facing many barriers in access to FP services in Nepal [5,8,9]. One in 200 women dies from pregnancy-or delivery-related causes in their lifetime in Nepal [10].
Nepal made considerable health services access and improved maternal and child health services coverage over the last three decades [11,12]. However, the FP program has poor performance and has low and stagnant progress in contraceptive prevalence rate (CPR) [13]. The Nepal Demographic Health Survey (NDHS) 2016 [12] revealed that CPR for modern contraceptive methods in Nepal was 43%, with 24% unmet need. Women from the poorest households, living in remote areas, disadvantaged ethnicities, religious minorities, and those with no education had poor knowledge and the lowest practice of contraceptive methods [14]. Many health system factors have contributed to poor progress on practices of contraceptive methods, including poor access to contraceptive methods, lack of contraceptive methods in health facilities [15], poor uptake due to perceived side effects, lack of proper counselling services on contraceptive methods and religious and cultural beliefs and value system [16,17]. Muslim women have low CPR (25.4%), high unmet need (37%) for modern contraceptive methods, high fertility and large family size in Nepal [18,19]. In Nepal, the total fertility rate has increased from 4.6 (2006) to 4.9 (2011) in Muslim populations [18]. Muslim groups had unintended pregnancies leading to the highest maternal mortality ratio (318 per 100000 live births) in Nepal [20] which suggests the need for quality FP services delivery and utilisation among Muslims.
Past evidence showed the knowledge and attitude contributed to the utilisation of modern contraceptive methods [21]. Other socioeconomic and demographic determinants were also identified as determinants of contraceptive methods such as women's age, education, number and sex of children, occupation, and access to a health facility [3,17]. However, limited evidence 4 available on the status of knowledge and practices of modern contraceptive methods and their associated determinants among Muslim women in Nepal. Therefore, we aimed to address research gaps among Muslim women of Mid-western Nepal. The findings of this study could inform policymakers and program managers to design contextual policies and programmatic strategies for universal coverage of contraceptive methods among the Muslim population.

Policy and services delivery context of FP in Nepal
Family planning program is the oldest public health program in Nepal [19], and FP services are  [24]. The FP Costed Implementation Plan 2015-2021 has also highlighted the cost and implementation strategies [25]. However, these policies and programs approaches are implemented one-size-fits-all approach [19]. There have not been focused and context-specific implementation strategies to recognise religious and cultural consideration for addressing FP needs of marginalised populations.
In Nepal, modern contraceptive services provided from different outlets ranging from community to tertiary level ( Figure 1). Services outlets include community clinics, health posts, static health clinics, and mobile health camps from different public, private, and private nonprofit sector health institutions. In addition, several short-term modern contraceptives are available at peripheral facilities. In contrast, long-term modern contraceptives are being provided in health posts (HP), primary health care centers (PHCC) and hospitals [26].

Muslims in Nepal
The Muslim community is a religious minority, socially excluded, and disadvantaged group in Nepal [19], consisting of 4.4% of the total population [27]. Most of them live in Terai districts Banke, Rautahat, Kapilvastu, Parsa, Mahottari, Bara and Sunsari. A smaller proportion resides in some hills and mountain districts Achham and Arghakhanchi of Nepal. Muslims are economically, socially, educationally, and politically backwards and deprived of various facilities, including health services [28]. As a result, they have one of the least human development index (HDI) of 0.41 [29] and the highest MMR [8].

Study design and setting
A community-based cross-sectional study was carried out between June and September 2019 in Khajura Rural Municipality of Banke district. The study population was married Muslim women with reproductive age of 15 to 49 years. The Khajura Rural Municipality was selected purposively. In this municipality more than one in four (26.7%) people belong to Muslim backgrounds [27]. The total population of 50,961 of Khajura Rural Municipality lives in 10,288 households. 27,457 were females, including 19,397 of reproductive age (15 to 49 years) group [27]. Four wards (of eight wards) of the municipality were selected randomly for the household survey. There was an estimated total of 1,750 Muslim married women of reproductive age (MWRA) in those selected wards [30].

Sampling and participants selection
The sampling frame of this study was married Muslim women aged 15-49 years. The sampling frame of Muslim MWRA was obtained from the selected ward office. Sample size was calculated using formula N=Z2pq/d2 where [Z=1.96, p=0.44 q=0.56), d =0.05] and 44% prevalence rate [31]. We determined 379 as the minimal sample size. Considering non-response rate of 10%, a sample of 400 Muslim women were interviewed among 1,750 Muslim MWRA.
We selected participant through a systematic random sampling method. The first women were selected randomly, and then every fourth (having a gap of three) women were selected for the interview. If there was more than one MWRA in the family, the youngest women were included in the study. Likewise, the adjoining households were recruited if the participants were not available in the selected households.
How are they deprived from the other population?
Need to clarify where is the ward? Is it hospital setting? sample size calculation needs to be base on the two DVs ; practice and knowledge.Author only cxalculatedbased on the practice. By right, need to use the two sample proportion sample size calculation. The author should demonstrate the highest sample size to ensure sufficient power.

6
Conceptual framework of the study Figure 2 illustrates the determinants of knowledge and practices of modern contraceptive methods. We adopted and revised the conceptual framework developed by Abebe Gizaw and colleague (2011) [32].

Study variables
Based on previous studies in Nepal and elsewhere [19,33,34], explanatory variables were basic socioeconomic and demographic variables. Demographic factors were respondent's age (≤18 years,19-29 years and ≥30 years), parity (0 to 2 and ≥3), respondent's family type (nuclear and joint family) [35]. Socioeconomic variables were respondent's education (illiterate those cannot read and write, basic education, secondary and above), respondent's occupation (agriculture, daily wage workers and housewives). Similarly, husband's occupation (agriculture, business and service, daily wages worker and foreign migrant worker) and family monthly income (≤20000 NRs and >20000 NRs (120 Nepalese Rupees=1 USD, 2022). Additionally, access to FP service variable included: health facility visits for FP counselling (yes/no). Knowledge of modern contraceptive methods was also included as the independent variable for practices of modern contraceptive methods. Based on ten knowledge-based questions, a composite measure of knowledge was created.

Outcome variables
Two outcome variables were included: knowledge on modern contraceptive methods (good and poor knowledge), and practices of modern contraceptive methods (yes or no). Knowledge on modern contraceptive methods was created using 10 sets of questions related to modern contraceptives such as ever heard about family planning (yes/no), female sterilisation is one way to avoid pregnancy (yes/no), oral contraceptive pills do not guarantee 100% protection (yes/no), women using the birth control injectable must get an injection every three months (yes/no), using both a condom and the pills is considered to be very effective (yes/no), use of contraceptive prevents unwanted pregnancies (yes/no), contraceptive methods are appropriate to space childbirths (yes/no), condom provides dual protection (prevents STI/HIV and unplanned pregnancies) (yes/no), contraceptive education is important for women who want to use contraception (yes/no), and common side effects of contraceptive pills include mood swings and weight gain (yes/no). Knowledge of modern contraceptive methods was then scored by assigning one point for each correct response. We considered a score of mean and above 'Good Knowledge' and a score of below mean 'Poor Knowledge' [7,36]. To assess the practice of modern contraceptive methods, women were asked if they used modern contraceptive methods in the last six months prior to this survey and coded their response as 'yes' or 'no'.

Data collection tools and techniques
A questionnaire on knowledge and practice of modern contraceptive methods were adopted from the previous studies [19,31,37] and survey [12]. The structured questionnaire was first developed in English, then translated into Nepali and local language (Awadhi). It was pretested among 20 women aged 15-49 years in adjoining ward to refine it. Necessary adjustments were made, including in the flow of questions patterns and language style. The local language was used in data collection. A face-to-face interview was conducted in participant's households. The interview was carried out in a separate area of participants' households to ensure confidentiality.
Participation was voluntary, and none approached respondents refused to be interviewed. Data were collected by local enumerators consisting of 3 females. The enumerators were the local Muslim community. They were recruited based on their educational background, local language knowledge, and prior data collection experience. The two days training was provided to the WHo translate and how is the process? enumerators about the study purpose, methodologies, tools, and techniques before preceding the actual data collection. All the data collection related field activities were closely supervised and monitored by the second author (YKC).

Data analysis
Data analysis was performed using SPSS version 25.0 (SPSS Inc., Chicago, IL). The collected data were entered, coded, and cross-checked to ensure consistency. Descriptive analyses were employed and reported as frequencies and proportions. The Chi-square test was conducted to assess the association between independent and outcome variables. Binomial logistic regression was examined to identify the determinants of knowledge and practices of modern contraceptive methods. Odds ratio with 95% confidence interval (CIs) were reported. The significance level was set at p < 0.05 (two-tailed).

Ethical approval was obtained from the ethical review board of Nepal Health Research Council and educational and administrative ethical committee, faculty of Nursing and Medical College of
Xi'an Jiaotong University, China, for this study. Before the collection of data, written permission was obtained from the local administrative authority Khajura Rural Municipality of Banke district. Before the interview process, enumerators and the second author (YKC) met Muslim religious leaders, shared the objective of the study, and obtained their permission to meet and collect data from their community. Verbal informed consent was obtained from participants before conducting the interview. The respondent's participation was voluntary where the respondents had the right to refuse the interview process. Table 1 shows the distribution of respondents accordingly to sociodemographic characteristics, the prevalence of knowledge and the use of modern contraceptive methods. Nearly half (46%) of the respondents were between 19-29 years, with an average age of 29 years. Over three-quarters of respondents (78.5%) had 0 to 2 living children, and almost half (48%) of respondents had primary level education. Approximately half (49.5%) of respondents were housewives, while 37% of respondent's husbands were involved in the agriculture sector. Over 6 in 10 respondents had >20000 NRs family monthly income. Almost two thirds (69.2%) of respondents had good what is the mean of knowledge score? what is the mean of age? 9 knowledge of modern contraceptive methods, and 47.3% of respondents used modern contraceptive methods. Injectable (43.4%) was the most used modern contraceptive, an implant (3.7%) was the least used contraceptive. Additionally, over 7 in 10 (71%) respondents ever visited a health facility for FP counselling (Table 1).    were more likely to practice modern contraceptive methods compared to those who had poor knowledge on modern contraceptives and those who have not visited HF for FP counselling respectively (Table 3).

Results
why remove FP counselling as IV to knowledge? why the salary is cut off at 20000? Why were the occupations divided as such? why doesnt the "ever visit to hospital" not included inside the regression.

Discussion
This study showed that two-thirds of Muslim women had knowledge, and two in five women practised modern contraceptive methods. Knowledge of modern contraceptive methods was low among the women working in agriculture and living in nuclear families. The practice of modern contraceptives was poor among women with no education, lived in a nuclear family, husbands working in the agriculture sector, women having poor knowledge on modern contraceptive methods, and who didn't receive FP counselling at health facility.
This study revealed that 69% of women had good knowledge of modern contraceptive methods.
Past studies reported mixed results on knowledge of modern contraceptive methods in Nepal. For example, a previous study (2016) reported low (44%) knowledge on modern contraceptive methods among Muslim women in Nepal [31]. Another study showed relatively higher (94.5%) knowledge on modern contraceptive methods in Nepal [38]. About 87% of women knew contraceptive methods in India [39]. Exposure to FP information through mass media message dissemination, community HWs and Female Community Health Volunteers (FCHVs) in the study area might have helped acquire good knowledge on modern contraceptive methods.
Despite high proportion of good knowledge on modern contraceptive methods, Muslim women had low practices of modern contraceptive methods in Nepal. The religious beliefs, societal pressure and fear of going against religious values could be a potential driving force of lower practices of modern contraceptive methods [40]. Our study's finding is consistent with past studies conducted in Bangladesh [41], and India [42]. Injectable was the most practised modern contraceptive method, followed by oral contraceptive pills. Similar to our findings, previous research conducted in the eastern district of Nepal also reported injectables as the most used contraceptives (53.1%), followed by oral contraceptives (24%) [31]. Likewise, another study conducted in the Kapilbastu district in Nepal reported that injectable (51.3%) was the commonly used contraceptive method followed by oral contraceptive (25.6%) [19]. Injectables are the most preferred modern contraceptive methods among Muslim women in Nepal. Their popularity could be due to their simplicity, effectiveness for three months and accessibility even in private pharmacies at low cost [43].
The knowledge of modern contraceptive methods was influenced by several socioeconomic factors such as family type and occupation of women. The current study revealed that women The first sentence of the first paragraph is redundant with the first sentence on the second paragraph.
There is no discussion regarding religion issues and cultural issues that influence the uptake of Family planning. especially when there are acceptable level of knowledge among them.
And how does the lack of accessibility influence them since many of themn are using the injectable form which needs HCP to insert.
Any potential influence from social circle? in law?
who lived in the nuclear family and were involved in the agricultural sector had poor knowledge of modern contraceptive methods. The women belonging to a nuclear family may have limited exposure to other family members, resulting in less opportunity to obtain information about contraceptive methods. The finding of this study is consistent with the study conducted in India [44]. However, previous studies in Nepal have reported no association between type of family and knowledge on modern contraceptive methods [31,38]. This could be because those women working in the agriculture sector might lack access to information on contraception Several determinants such as education, good knowledge of contraceptive methods and access to counselling services were positively associated with the practices of modern contraceptive methods. Studies from Nepal [17,31] and other Asian countries [45] have reported increased practices of modern contraceptive methods with increased education [17,45]. The findings of the current study are consistent with the previous studies conducted in Nepal [31], Bangladesh [41], and India [42]. The illiterate women may have limited access to contraceptives, leading to a lack of awareness about the benefits of contraceptive use. Furthermore, those women may not openly discuss contraceptives with their spouse due to lower autonomy in marital relationships [21,46].
Previous evidence showed that illiterate Muslim women tended to become unaware of their reproductive rights and were very reluctant to visit health facilities for FP services [18].
Past evidence documented that having good knowledge of contraceptive methods may increase the practice of these contraceptives [21,47]. Our study also showed that women's knowledge of modern contraceptive methods was related to their practice. Women who had good knowledge were more likely to practice modern contraceptive methods than those with poor knowledge.
This might be because women with good knowledge may know better about the benefits of contraceptive use, and it would increase the women's decision making power for the practice of contraceptives [48]. Moreover, access to FP counselling was another factor affecting contraceptive practices in our study; women who had ever visited a health facility for FP counselling were more likely to practice modern contraceptive methods than those who have not visited. The women who ever visited a health facility for FP counselling might be aware of the benefits of contraceptive use so, and they have favourable behaviour for the practices of contraceptive methods. A similar study conducted from abroad reported consistent findings [49].
why is it that nuclear family has lower knowledge but higher practice than joint family? Does this infer cultural influence?

Programmatic implications
This study has highlighted some implications for policy and programs. First, the current study revealed gaps in good knowledge in modern contraceptive methods but poor practices of modern contraceptive methods. These women groups require accessible quality of contraceptive choices.
The concept of roving midwives service providers can be adopted and implemented to offer

Strength and limitation of the study
This study has some strengths. We have used pretested and well-designed questions and trained interviewers from the local community. The study has explored the factors influencing the practice of modern contraceptive methods among most unreached groups. However, this study has some limitations: First, it was a survey design that does not provide us with inferences regarding causality. Second, some of the important covariate such as distance to a health facility where FP service is available and cost that previous studies found important predictor of contraceptive practices were not included in this study [50,51]. Third, this study cannot be generalised to all populations as this study was conducted among Muslim women. Though this what do you mean by gaps in knowledge?clarify dont see this being discussed. Seems like even primary health care is offering a few options of contraception. so why are Muslim women not forthcoming for FP? Any restriction by the healthcare system or political provision? study provided a cross-sectional analysis of knowledge and practices, a qualitative study can explore the underlying drivers of gaps in high knowledge and low practices of modern contraceptive methods among Muslim communities in Nepal.

Conclusions
The practice of modern contraceptive methods is relatively low despite having satisfactory